NCM 101: HEALTH ASSESSMENT b.

Consists of a mini-overview of
the client’s body systems and
Lesson 1: NURSING DATA COLLECTION, holistic health patterns as a
DOCUMENTATION, AND ANALYSIS follow up on health status.
NURSING PROCESS: 3. Focused/Problem-Oriented
Assessment
STEP 1: ASSESSMENT a. Does not replace the
comprehensive health
-is the first and most critical phase in nursing
assessment
process.
b. Performed when the
-gathering information about the health status of comprehensive database exists
the client. for a client who comes to the
healthcare agency with a specific
-analyzing and synthesizing data, making health concern.
judgements about the effectiveness of nursing 4. Emergency Assessment
interventions, and evaluating client care a. Very rapid assessment
outcomes. performed in life-threatening
situations (choking, cardiac
Focus of HA in Nursing: collect holistic subjective
arrest, drowning).
and objective data to determine a client’s overall
level of functioning in order to make a professional Steps of Health Assessment:
clinical judgement.
Before proceeding to the 4 main steps, remember to
Framework for HA in Nursing: helps to organize prepare for the assessment (review medical record,
information and promotes the collection of holistic knowing basic biography of the patient, etc.)
data.
1. Collecting Subjective Data:
- History of present health concern a. Subjective data are sensations or
- Personal health history symptoms, feelings, perceptions,
- Family history desires, preferences, beliefs,
- Lifestyle and health practices ideas, values, and personal
information that can be elicited
Pender’s Health Promotion Model:
and verified only by the client.
- Individual characteristics and i. Biographical information
experiences ii. History of present health
- Behavior-specific cognitions and concern
affect iii. Personal health history
- Behavioral outcomes iv. Family history
v. Health and lifestyle
Types of Health Assessment: practices
1. Initial Comprehensive Assessment vi. Review of systems
a. Collection of subjective data 2. Collecting Objective Data:
about the client’s perception of a. Obtained by general observation
his or her health of all body parts using the four physical
or systems, past health history, examination technique
family history, and lifestyle and (inspection, palpation, percussion,
health practices. auscultation)
2. Ongoing or Partial Assessment i. Physical characteristics
a. Consists of data collection that ii. Body functions
occurs after the comprehensive iii. Appearance
database is established. iv. Behavior
v. Measurements
 vi. Results of laboratory a.
After introducing herself to the
testing client, the nurse explains the
3. Validating Assessment Data: purpose of the interview,
a. Crucial part of the assessment discusses the types of questions
that often occurs along with that will be asked, explains the
collection of subjective and reason for taking notes, and
objective data. assures the client that
4. Documenting Data: confidential information will
a. Forms a database for the entire remain confidential.
nursing process and provides 3. Working Phase:
data for all other members of the a. The nurse elicits the client’s
healthcare team. comments about major
biographical data, reasons for
STEP 2: NURSING DIAGNOSIS/ANALYSIS OF seeking care, history of present
ASSESSMENT health concern, past health
-Second phase of the nursing process history, family history, review of
body systems for current health
-analysis of the collected data goes hand in hand problems and lifestyle and health
with the rationale for performing a nursing practices.
assessment. 4. Summary and Closing Phase:
a. The nurse summarizes
-by NANDA: a clinical judgement concerning a
information obtained during the
human response to health conditions/life processes,
working phase and validates
or a vulnerability for that response, by an
problems and goals with the
individual, family, group, or community. A nursing
client.
diagnosis provides basis for selecting nursing
interventions to achieve outcomes for which the Communication during the Interview:
nurse is accountable”
1. Nonverbal communication –
Process of Data Analysis: appearance, demeanor, posture, and facial
expression.
- Identify abnormal data and strengths
a. Appearance – should be
- Cluster the data
professional
- Draw inferences and identify
b. Demeanor – should be
problems
professional
- Propose possible nursing diagnosis
c. Facial Expression – monitor
- Check for defining characteristics of
them closely
those diagnosis
d. Attitude – nonjudgmental
- Document conclusions
e. Silence – allows your client to
Factors Affecting Health Assessment: organize thoughts
f. Listening – maintain eye contact
- Culture, family, and community may and display open body position
all affect client’s health status. 2. Verbal communication – the goal is to
elicit as much data about the client’s
Lesson 2: COLLECTING SUBJECTIVE DATA: THE
health status as possible.
INTERVIEW AND HEALTH HISTORY
a. Open-ended questions –
Phases of the Interview: require more than one word as
response
1. Pre-introductory Phase: b. Close-ended questions –
a. Nurse reviews medical record answerable by yes or no; limited
before meeting the client answer
2. Introductory Phase:
 c. Laundry list – list of words to 4. Personal health history
choose from in describing a. Questions related to the client’s
symptoms personal history, from the
d. Rephrasing – clarify information earliest beginnings to the
e. Well-paced phrases – present.
encourage client verbalization 5. Family health history
f. Inferring – observe client a. Should include as many genetic
behavior relatives as the client can recall.
g. Providing information – 6. Lifestyle and health practices profile
provide information to client a. It deals with client’s human
responses.
Special Considerations during the Interview:

1. Gerontologic Variations in
Communication Lesson 3: COLLECTING OBJECTIVE DATA: THE
a. Age affects and commonly shows PHYSICAL EXAMINATION
all body systems to varying
degrees. Physical Examination Techniques:
2. Cultural Variations in Communication 1. Inspection – using the senses of vision,
a. Ethnic/cultural variations in smell, and hearing to observe and detect
communication and self- any normal or abnormal findings.
disclosure styles may 2. Palpation – consists of using parts of the
significantly affect the hand to touch and feel the following
information obtained. characteristics:
3. Emotional Variations in i. Texture
Communication ii. Temperature
a. Not every client you encounter iii. Moisture
will be calm, friendly, and eager iv. Mobility
to participate in the interview v. Consistency
process. vi. Strength of pulses
Complete Health History vii. Size
viii. Shape
1. Biographical data ix. Degree of tenderness
a. Name, address, phone number, b. Light Palpation – use this
gender, who provided the technique to feel for pulses,
information – the client or tenderness, surface skin texture,
significant other and moisture
b. Birth date, social security c. Moderate Palpation – depress
number, medical record number, the skin surface 1-2 cm with your
health insurance information dominant hand; note the size,
2. Reason(s) for seeking health care consistency, and mobility
a. What is your major health structures
problem or concern at this time? d. Deep Palpation – non-dominant
How do you feel about having to hand over dominant hand on skin
seek healthcare? surface and apply pressure; feel
3. History of present health concern very deep organs or structures
a. Takes into account several e. Bimanual Palpation – placing
aspects of the health problem two hands on each side of the
and asks questions whose body; note the size, shape,
answers can provide a detailed consistency and mobility
description of the concern.
 Parts of Hand to Use: stirrups. (female genitalia, reproductive
- Finger pads – pulses, texture, size, tract and the rectum)
consistency, shape
- Ulnar or palmar surface –
vibrations, thrills, fremitus Lesson 4: VALIDATING AND DOCUMENTING
- Dorsal - temperature DATA
3. Percussion – tapping body parts to
produce sound waves; determines: Purpose: confirming or verifying subjective and
a. Eliciting pain objective data
b. Determining location, size and
Data Requiring Validation:
shape
c. Determining density 1. Discrepancies or gaps between the
d. Detecting abnormal masses subjective and objective data
e. Eliciting reflexes 2. Discrepancies or gaps between the client
Types of Percussion: says at one time and another time
- Direct Percussion – direct tapping 3. Findings that are highly abnormal
on the body
- Indirect Percussion – most Methods of Validation:
commonly used percussion
1. Recheck data
- Blunt Percussion – using one flat
2. Clarify data
hand on the body surface and using
3. Verify the data
the fist of the other hand to strike
4. Compare your objective from subjective
4. Auscultation – requires the use of
stethoscope to listen for heart sounds, Documenting Data – is addressed specifically by
movement of blood, bowel, and air. various state nurse practice acts
Positions: Purpose: promote effective communication
among healthcare members
1. Sitting position – sit upright (head, neck,
lungs, back, breast, axillae, heart, vital
signs, upper extremities)
2. Supine position – lie down with legs Lesson 5: THINKING CRITICALLY TO ANALYZE
together (head, neck, chest, breast, axillae, DATA AND MAKE INFORMED NURSING
abdomen, heart, lungs and all extremities) JUDGEMENT
3. Dorsal Recumbent position – lie down Data analysis = diagnostic phase/clinical reason
with knees bent and legs separated (head, phase
neck, chest, axillae, lungs, heart,
extremities, breast, peripheral pulse) Assessment of Data – includes health promotion,
4. Sims’ position – lies on left or right side risk, actual, collaborative, and referrals to
with the lower arm placed behind the healthcare providers.
body and upper arm flexed at the
shoulder and knee while lower leg is Diagnostic Reasoning Phase – profound effect
slightly flexed. (rectal and vaginal areas) on the conclusions you reach in analysis of data
5. Standing position – stands still (male 1. Identify strengths and abnormal data
genitalia) 2. Cluster data
6. Prone position – lies down on the 3. Draw inferences
abdomen with head to the side (hip joint) 4. Propose possible nursing diagnosis
7. Knee-Chest position – kneels with the 5. Check for defining characteristics
weight of the body supported by the chest 6. Confirm or rule out diagnosis
and knees. (rectum) 7. Document conclusions
8. Lithotomy position – lies back and hips
at the edge and feet supported by Actual Nursing Diagnosis – most useful format
Wellness/Health Promotion Diagnosis –
represent a client that may or may not have a
problem travelling

Risk Diagnosis – vulnerable to an actual

Syndrome Nursing Diagnosis – specific cluster

Collaborative Problems and Referrals – should